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PAHO Basic Health Indicator Data Base This is a multidimensional query tool that offers a collection of 108 indicators from 1995 to 2005. The system presents data and indicators on:
- demography
- socioeconomic
- mortality by cause indicators
- morbidity and risk factors
- access, resources and health services coverage.
Selected indicators are disaggregated into age groups, sex and/or urban/rural region. Generated tables can be exported and printed.
The data presented is updated annually with the latest country information.
Background: In 1999, the country began a political, legal, economical and social transition process with the objective to initiate a new development model that strengthens the democratic system. The political transition has allowed the writing of the new Constitution of the Bolivarian Republic of Venezuela (CBRV), and the beginning of the reorganization of the State, including the creation of a Citizen Power that is integrated by the Attorney General Office, the National Comptroller Office and the People’s Ombudsman. The importance of health as an integral part of the development, is recognized in the new CRBV. The government policy to overcome poverty proposes a strategy of social and productive integration through the active participation of the community, and the applying of a massive social strategy called “Miosnes”. One of the lines of that strategy is health-oriented and it is known as “Misión Barrio Adentro” (Inside the Barrio Mission, in English), whose main objective is to increase the access coverage to basic health services with quality and equity.
Demography: The Bolivarian Republic of Venezuela (BRV) is a federal state organized in 23 federated states, a capital district and the federal dependencies. It has an area of 916,446 sq km with a 26,008,481 population (2004), with a population density of 28.4 inhabitants/sq km, and an annual growth rate of 1.9%. People under 15 years of age and above 60 years are 32.1% and 7.3% of the total population, respectively. In 2002, the birth and mortality rates were 23.2 per 1,000 and 4.6 per 1,000 inhabitants, respectively. The general mortality rate was 3.8% among women and 5.7% among men. In that same year, 87.4% of the population lived in urban areas; 53% lived in the north coast region, 24% in the border areas, and 23% in the central regions. In 2001, the indigenous population was 1.5% of over all population. Life expectancy at birth (LEB) during the 1990-1995 period was 74.7 years in women and 68.9 years in men, while in the 1995-2000 quinquennium LEB was 75.7 and 69.9 years among women and men, respectively. General LEB was 71.8 and 72.8 years in the respective quinquennia. In 2002 a LEB gap of 9.1 years was observed between the most and least developed states (75.2 in the capital district and 66.1 in Amazonas State) During the 2000-2005 period, general LEB was estimated in 74.1 years (71.3 among men and 77.1 among women).
Economy: It has been characterized by a slow growth with recurrent inflation and recession episodes in the last decade. The GDP per capita passed from $PPA 2,647 in 1998 to $PPA 3,477 in 2000. However, poverty levels have remained relatively stable in the same period (from 49.1% in 2000 to 48.6% in 2001-INE). Poverty varies greatly among states, from 48.1% in Delta Amacuro State to 29.2% in the capital district. In relation to the Human Poverty Index among developing countries, Venezuela passed from 8th position in 1999 to the 10th in 2001 (Informe IDH-2001). Inflation rate diminished from 103% in 1996 to 13.4% in 2000; it increased to 27.1% at the end of 2003. The Economically Active Population (EAP) were 16,336,902 persons in July, 2001; 11,005,694 (67.4%) are currently employed; on December, 2002 EAP and employed population were 12.008.719 and 9.993.806 (83,2%), respectively. Global rate of unemployment in the second semester of 2001 was 12.8% and rose to 16.8% during the same period of 2003. Among men, in the same semester of those years, the unemployment rate passed from 11.6% to 14.4%, while in women it rose from 14.6% to 20.3%.
Education: The enrollment rate in mid-level, diversified and higher education covers only 25% of the population that could enroll. In the last Census (2001), illiteracy rate among people above 10 years of age was 6.4% (9.3% in the 1990 Census). According to the Human Development Index (HDI), in 1999 the country occupied the 61st place (HDI-2001) and the 69th in 2001 (HDI-2003).
Mortality: During the 1995-2000 quinquennium, the highest estimated mortality rate, according to the six great groups of death causes, was due to circulatory diseases (138.0 per 100,000 inhabitants), followed by external causes (67.4 per 100,000), cancer (62.7 per 100,000), communicable diseases (46.6 per 100,000) and certain conditions originated in the neonatal period (22.4 per 100,000). In 1999, the analysis of mortality according to Potential Years of Potential Life Lost (YPLL) showed that accidents (15.8%) was the first cause of YPLL and they were followed by cancer (8.1%), suicide and homicide (6.8%) and heart diseases (8.1%). Chronic diseases and accidents are among the first three causes of death, though communicable diseases are still a problem. In 1999, ill-defined signs and symptoms amounted 1.4% of all registered deaths, and 1.5% in 1995. Estimated mortality under-registration in 1998 was 3.6%.
SPECIFIC HEALTH PROBLEMS
Analysis by vulnerable groups
Infant population (under 1 year of age): Between 1940 and 2002, infant mortality rate fell from 123 to 18.6 per 1,000 live newborns; the mortality was reduced in 85%. The speed of the fall is higher in the post-neonatal component than in the neonatal one. In 2002, the most significant causes of death were certain conditions originated in the neonatal period (55.7%), congenital malformations, deformations and chromosomal abnormalities (16.4%), and they are followed by certain infectious and parasitic diseases (11.3%), respiratory system diseases (5.3%) and external causes with a morbidity and mortality of 4.3%. Between 1990 and 2000, mortality due to diarrheic diseases in children under 5 years of age fell 80% (from 215.7 per 100,000 live newborns to 42.1), and the mortality due to acute respiratory infections fell 36%. In 2000 and in relation to morbidity, diarrheic and respiratory diseases occupied the first places. Low birth weight in 2000 was reported in 12% in the most important obstetric wards in the country.
Women in reproductive age (15-49 years): Maternal mortality rate diminished from 172 per 100,000 live newborns in 1940 to 68 in 2002. In 2002 in Venezuela 335 maternal deaths were registered, this means that every day occurred a maternal death. The most significant causes of maternal death were edema, proteinuria and hypertensive disorders (34%); other obstetrical disorders non classified in another part (17%), obstetrical complications related to labor and delivery (13%); obstetrical complications related to puerperium (13%) and pregnancy ending in abortion (11%). In some states almost 30% of these deaths occurred in women under 20 years. Considering that more than 95% of childbirths are physician-attended, most of these deaths are preventable improving the quality of health care. Studies carried out in 2000 showed that 16.5% of women in reproductive age suffered anemia and that this percentage rose to 22% in the poorest population. The coverage of prenatal care in 1997 was 25.5% and it is currently about 50%. The total fertility rate in 2002 was 2.1 children per woman.
Adolescents (10-24 years): In 2003, the adolescent population was 33% of the total Venezuelan population. In 1998, seven out of ten adolescents lived in a poor household; almost 40% of adolescent population between 15-17 years of age were excluded from the regular educative system. The average age for male premarital intercourse is 14 years, and in women is 15, usually with older sexual partners and without protection. The fertility rate among adolescent women between 15-19 years of age has diminished in the last ten years from 97 to 87 live newborns per 1,000 women, though; its contribution to the total fertility has risen. In 2002, the main causes of morbidity among adolescents were concentrated in psycho-social and family problems, like family dysfunction, depression, poor school performance, suicidal behavior, alcoholism and use of illegal drugs, and intra-family violence. Among the first causes of death are the accidents, violence, suicide and homicide; death causes related to motherhood are in 7th place.
Elders (above 60 years): In 2002, the population above 60 years of was 6.5% of total population (46%, men and 54%, women). It can be expected that this population will grow three-fold in the next 25 years. In the same year, the main causes of mortality were heart diseases (32%), cancer (18%), cerebrovascular diseases (12%) and diabetes (8%). The risk of dying of these causes is higher in men than in women, but in diabetes. The main causes of morbidity are blood hypertension, followed by flu-like syndrome, diabetes, urinary infections and rheumatoid arthritis.
Indigenous population: According to the last Indigenous Census (1992), there were 371,815 indigenous inhabitants (1.5% of total population). This population was integrated by 38 ethnic groups: Wayu (54.5%), Warao (7.6%), Pemón (6%), Añú (5.5%), Yanomami (4.7%), Guajibo (3.6% and Piaroa (3.6%). These groups represent 84.4% of the total indigenous population. (3,6%). The states where indigenous population is concentrated are Zulia (62.4%), Amazonas (14%), Bolívar (11%) and Delta Amacuro (6.6%). In 1992, more than 50% of those communities did not have drinking water, nor sanitary excreta disposal means and 65% did not have a school. According to partial data of investigations done in determined ethnic groups, the main causes of morbidity are TB, malaria, parasitic diseases, malnutrition, diarrheic and respiratory diseases.
Handicapped population: It is estimated that 10% of the total Venezuelan population suffers some kind disability, dysfunction o incapacity.
Analysis by type of disease or damage
Malaria: In 2003, 31,719 cases were diagnosed; 31,186 were originated in the country and 533 were imported. This represents a 26% increase in the disease transmission in relation with the expected level. 97.8% of all cases have occurred in five states, that also have a high annual parasite index (API): Bolívar (13,982 cases, API 9.9 per 1,000 inhabitants); Amazonas (9,262 cases, API 89.4); Sucre (5,266 cases, API 6.2); Delta Amacuro (1,489 cases, API 9.7) and Zulia (496 cases, API 0.14). At a national level in 2003, the parasite distribution formula was: 26,195 cases (82.6%) were due to Plasmodium vivax, 5,294 (16.7%) due to Plasmodium falciparum; 191 (0,6%) due to P. vivax and P. falciparum coinfection and 39 (0.1%) due to Plasmodium malariae.
Dengue: Serotypes 1, 2 and 4 have circulated simultaneously in the last years; serotype 3 was detected in 2000. The most important epidemic outbreaks have occurred in 1990, 1994, 1995, 1997, 1998 and more recently, in 2001 and 2002 (incidence rate of 337 per 100,000 inhabitants and 152.96, respectively) with a proportion of Hemorrhagic Dengue (HD) ranging from 7-10%. Thirty one deaths due to HD occurred in 1999 and 13 until October, 2001. One of the predisposing factors for the occurrence of the outbreaks is the high Aedes index which was higher than 40% in some cities.
Tuberculosis: In the last years bacilliferous pulmonary tuberculosis and the other forms of the disease have not changed. In 1991, the rates were 15.6 and 26.1 per 100,000 inhabitants respectively and 15.0, and 25.2 respectively in 2000. At a national level, the BCG-vaccine coverage is above 95%, and more than 85% of patients are given DOTS. In 2001, 79.8% of patients were cured; this was an improvement with respect to 1992, when 66.4% were cured. However, the treatment abandonment rate has increased from 8% in 1992 to 10.6% in 2001. The failure index (positive persistent cases in the bacilloscopy) in treated patients improved; it was 0.6% in 1992, and in 2001 it was 0.4%, while the case fatality rate passed from 2.8% in 1992 to 4.5% in 2001.
In 2002, 3,998 (85.7%) of 4,666 health facilities of the Health and Social Development Ministry (HSDM) were integrated to the Tuberculosis Program. The integration of other facilities not depending on the HSDM is lower than 50%. There are 457 clinical laboratories that depend on the HSDM, and 73.7% of them can process samples for mycobacteria detection. The assessment results of the slides received at the National Reference Tuberculosis Laboratory (NRTL) had a 98.9% concordance.
From 1994 to 2000, the percentage of identified respiratory symptomatic cases (IRSC) in people above 15 years of age fell from 6.9% to 3.6%, a value lower than the expected 5%; the percentage of bacilloscopies done to IRSC rose from 29.1% to 53.2%. The total of programmed bacilloscopies is accomplished only in 23.5%. During the last quinquennium, less than 65% of all IRSC were examined. In only about 50% of them a second sample was processed. The proportion of positive cases detected through first examined bacilloscopies in ISRC fell in the last decade from 5.9% to 3.9%, which is still above the expected 2% determined by the National Program. The proportion of positive bacilloscopies is 1.5, index that is considered as acceptable. In 2002, the detection of bacilliferous cases in persons above 15 years was 60%. There were 729 deaths due to tuberculosis in 1999. In the 15-49 years age group the death average for each age year was seven, which is very similar to the death average (eight) for all age groups.
AIDS: During the 1983-1999, 8,047 cases and 4,726 deaths were registered; it is estimated that there is a significant under-registration. According to UNAIDS, the number of people living with HIV in 1999 was 62,000 (less than 0.5% of all population). However, there are no reliable data about the real number of HIV carriers. Cumulated annual incidence was 4.8 per 100,000 inhabitants. Analyzing the cumulated incidence, the main mode of transmission (90.3%) was the sexual (homosexual, 41.5%; heterosexual, 31.7% and bisexual, 17.1%) followed by the blood-borne transmission (4.3%: intravenous drugs, 2.%; hemophilia, 1.3% and through blood transfusion, 1.0%); vertical transmission (3.1%) and mixed modes (2.3%). Although there is a evident predominance of male cases, the incidence among women is rising (the men-women ratio was 10:1 in 1990 and 5:1 in 1999). 50% of cases were 15-24 aged when infected. The most affected age group is the 25-34 years. In 1999, there were 1,234 deaths; the death average for each age year was 2.4 greater for the 15-49 year age group in comparison with the death average for all other ages. To provide care to people living with HIV/AIDS the HSDM has increased the budget of HIV/AIDS program from 2,915,361 USD (1999) to 43,068,641 USD in 2001.
Vaccines preventable diseases: Immunization coverage in 2003 was, in general terms, below the international standards (95%). Only 67% of the population under 1 year of age received three doses of DPT due to supply related problems of this vaccine. The coverage for polio, BCG and measles vaccines were 86%, 91% and 82%. Between 2000 and 2001, new vaccines were added to the regular vaccination scheme: Haemophilus influenzae type B, Hepatitis B and Yellow Fever vaccines. Coverage for these vaccines were 56%, 75% and 82%, respectively.
Since 1997, there have been no measles cases in the country until the 35th week of 2001, when an outbreak, due to imported virus from Europe, began in Falcón State and spread to the whole country. The outbreak was controlled by the 47th week of 2003 and 2,501 cases were confirmed, 84% of them occurred in the Zulia State. Since 2001 the country buys vaccine and syringes through the PAHO Rotational Fund.
Zoonoses: In the last two years, Venezuela’s Zoonoses National Commission has worked regularly. In relation to urban rabies in the Zulia State (west of the country), since 2000 canine rabies exhibits a sustained increase in the number of cases with a progressive spread outside of Maracaibo and its direct influence zones where it was traditionally concentrated. In the same way, human rabies cases, which have not been registered since 1998, reappeared with two deaths in 2003 and with two other deaths occurring until August, 2004.
No epidemics of Venezuelan Equine Encephalitis has been registered since 1995, and there is an increase in the circulation of the Eastern Equine Encephalitis virus with no consequences to human health. The circulation of West Nile Virus is under surveillance and a national network for the diagnosis of leptospirosis is being implemented.
Food safety: Although, there is a significant under-registration, between 1996 and 2000 there was a 63% increase in the number of food-borne diseases outbreaks and cases, which grew four-fold. The contaminant agent was isolated in 56.4% of the times; 72.8% of all cases were due to Staphylococcus aureus, 14.7% were relate to histamine. In 2000, half of the events occurred within households and 22.8% were registered in schools. White soft cheese was the most frequent involved food in food-borne outbreaks and cases and Staphylococcus aureus was the most frequent isolated agent.
Yellow Fever: In 1998, there was an outbreak in a Yanomami hamlet in the Parima region in the Amazonas State; it caused 15 cases and four deaths. Between the 48th week of 2002 and the 39th week of 2003, there was a outbreak that caused 46 cases and 23 deaths (case fatality rate: 50%) in the Zulia, Táchira and Portuguesa States. Nine cases (including six deaths) came from Colombia and were detected by the surveillance system of the Zulia State. Yellow Fever vaccine is provided to children less than 1 year of age within the regular immunization scheme since 2001.
Chagas disease: As a consequence of insecticide use and the housing improvement, it has diminished from around 45% in the 1950’s to less than 10% in the 1990’s. About six million people are in risk of contracting the disease. The seroprevalence incidence in 2000 was 8.3% while in children under 10 years it was 1%. Infestation index of Rhodnius prolixus passed from a house index of 0.7% in 1990 to 5.2% in 2000 (the highest of the decade). The house infection index to Trypanosoma cruzi rose from 0.04% in 1990 to 0.5% in 2000.
Schistosomiasis: The disease is prevalent in a zone located in the North Central Region with an area of 15,000 sq km (1.6% of the national area). The estimated population at risk are 1,690,970 inhabitants living in the Aragua, Carabobo, Miranda, Norte de Guárico States and the capital district.
Onchocercosis: The disease is a risk for 18.3% of the population of the Americas Region, Venezuela is the third most affected country. There are three foci: northeastern, north-central and south; within these foci there are 609 endemic communities, and 76.3% are located in the northeastern focus. People eligible to receive two annual doses for ten years are 84,492. The Ivermectine mass treatment has reached only 41% of its goal.
Cutaneous leishmaniasis: It is endemic in all the country, but in the Nueva Esparta State. It is more frequent in men aged 15-44 working in farm jobs. Ninety two percent of the 2,528 registered cases in 2000 presented the cutaneous localized form. States with an incidence higher than the national (10.5 per 100,000 inhabitants) are Mérida, Trujillo, Lara, Sucre, Táchira, Cojedes and Anzoátegui.
Leprosy (Hansen Disease): Since 1997, it is no longer a public health problem, though it persists in Cojedes, Portuguesa, Barinas, Apure and Trujillo States. Prevalence rate in 2000 was 0.6 per 100,000. The most prevalent form is the multibacillary.
Non Communicable Diseases
Cardiovascular diseases: In 1999, they were the first cause of death (21% of all deaths); more than 50% of all deaths caused by cardiovascular diseases were due to acute myocardial infarction. Hypertensive diseases provoked one out of ten deaths. Ischemic heart diseases show a rising trend, while this is not the case for hypertensive diseases; this supposes there is an under-registration for the last ones.
Cancer: In 1999, neoplasms occupy the second cause of death (14.3% of all deaths), digestive cancer, especially stomach cancer in both sexes. Among women uterine cancer was the second type of death (incidence rate 13.1 per 100,000 women); the highest risk occurred in women aged 25-64 (202.6 per 100,000 women). Breast cancer was the third cause (8.8 per 100,000 women).
Among men, lung and bronchial cancer occupied the second place (incidence rate. 11.4 per 100,000 men); prostate cancer was in third place (11.0), men above 50 years were the age group with the highest risk (74.9). It is estimated that more than 80% of cancer patients do not received adequate pain management and palliative care.
Diabetes: In 1999, it occupied the fifth cause of death (5.5% of all deaths); in women it was the fourth cause (7.4%). Mortality rate in that year was 23.8 per 100,000 inhabitants: 22.9 in men and 26.9 in women. The highest risk of dying occurred in women above 60 years of age (282.3 per 100,000). In comparison, the incidence rate among men of the same age was 222.1 per 100,000). In 1999 diabetes mellitus type 2 represented 87.9% of all diabetes cases; 10.6% of all cases were due to diabetes type 1, and 1.5% were caused by other types.
The most frequent chronic complications in 2000 were peripheral neuropathy (38%), diabetic nephropathy (25.7%), diabetic foot (23%), diabetic retinopathy (19%), peripheral vascular insufficiency (13.2%) and urinary infection (6.9%).
Accidents and violence: They caused 12.5% of all deaths in 1999. Accidents of all kind in that year were the fourth cause of death (7.5%) with an incidence rate of 32.8 per 100,000 inhabitants (51.0 in men and 16.1 in women), compared to 1989, the incidence rate in women was 39.5. Mortality due to motor vehicle accidents represents 60% of total mortality caused by accidents of all kind; it was the third cause of death among men and the sixth among women. In 1999, suicide and homicide caused 5% of all deaths, they were the seventh cause of general mortality and in men were the fourth cause (78.4%). Mortality trend for these causes is rising, especially due to homicide (incidence rate of 11.7 in 1998 and 16.9 in 1999); men aged 15-44 years are the age group with the highest risk (incidence rate of 430.2 per 100,000). During the first semester of 2000, mortality due to homicide was the fifth cause of death. Eighty three percent (7,908 deaths) of deaths due to suicide and homicide were caused by homicide; in comparison, in 1999 that percentage was 76%.
RESPONSE OF THE HEALTH SYSTEM
HEALTH IN HUMAN DEVELOPMENT
The CBRV establishes a judiciary, institutional adaptation process and new strategies to carry out the necessary changes to establish the bases to develop the judiciary nature and the organization model of the Venezuelan Health Sector. Article 83, establishes that health is a fundamental social right, an integral part of the right to live, and that it is an responsibility of the State to guarantee the right to health. Article 84, orders the creation of a national health public system, regulated by the HSDM, with an inter-sectorial nature, decentralized, integrated to the social security system, and ruled by the principles of gratuity universality, integrality, equity, social integration and solidarity. Article 85, establishes that financing of the national health public system is responsibility of the State. Article 86, establishes that every individual has right to social security as a public service of non-profit nature that guarantees health and insures protection to face different contingencies.
In this context a proposal of Organic Law of Health was formulated and it is pending of approval by the National Assembly which collects policy directions and establishes rules to their institutionalization.
In 1999, the Public Health and Social Assistance Ministry was merged with the Family Ministry and as a result the Health and Social Development Ministry (HSDM), which is the regulatory body of health sector. HSDM is responsible of regulation, proposal, design, evaluation, control and follow up of health and social development policies, programs and plans, as well as the integration of financing sources, the allocation of funds of the National Health Public System, the health care of all population sectors, especially the poorest, and the promotion of the community participation. HSDM has proposed as a priority the restructuring of its central level, the applying of an integral health care strategy to the population and the creation of a National Health Public System directed to overcome the emphasis devoted to curative medicine and oriented to actions that promote the social development of the country. The Health and Social Development Strategic Plan (2001-2007) attempts to guarantee the integral care of the population, especially among the most vulnerable groups; to prevent and control the prevalent morbidity and mortality and to guarantee the effectiveness, equity, and solidarity of the services of the health and social development system. This Plan is framed within the National Social and Economical Development Plan 2001-2007.
National health policies and programs: In 1990, began the decentralization process of the health services of the former Public Health and Social Assistance Ministry. The decentralization process marked a trend to the autarchy of the state and local health systems which produced very disparate developments depending on the political will of the local or state authorities and on the previous record of the service network of the zone and on the capabilities of the institutional facilities located there. In the process only 17 states were decentralized.
The Health System: It is integrated by public and private subsectors and by many agencies that fulfill the regulatory, financing, insuring and the care providing services functions. In 1997, population with some kind of insurance was 15,665,235 people (65% of the total population). The IVSS provided services to 57%. The ambulatory network of the HSDM provides care around 80% of the population. Large strata of the population do not have access or have very restricted access to health care.
Health Care Services Organization: The HSDM has 4,819 health care facilities, centralized and decentralized. Two hundred and fourteen are hospitals and 4,650 are of ambulatory nature. The ambulatory facilities are classified in Urban (type I, II and III), and Rural (type I and II). There are 890 urban facilities: 693 type I, 154 type II and 43 type III. There are also 3,715 rural facilities: 2,852 are type I and 863 are Type II.
The hospitals of the public network are 296 (214 depend on the HSDM or the state governments; 33 belong to the IVSS; 13 are of the IPFSA; three belong to PDVSA; 29 depend on the INAGER, two belong to the CVG; one to the Miranda municipality and one to the Caracas State Police). The private sector has 344 hospitals (315 profit institutions and 29 of non-profit institutions). In 2000, there were 40,675 count beds in the public subsector (17.6 beds per 10,000 inhabitants); more than 50% of those were located in the capital district and in the most developed states. This makes clear the inequity in the service coverage. Seventy percent of the HSDM budget is devoted to the hospital network; 20% to primary care and 10% to the system management.
Of the 4,819 health facilities, 95.6% (4,605) are part of the ambulatory care network. 19.3% (890) of the ambulatory facilities are urban and 80.7% (3,715) are rural; 61.9% (2,852) of the rural facilities are type I and 18.7% (863) are type II. In 2001, began the implementation at the ambulatory level of an integral health care strategy which attempts to improve the resolution capacity of the first level of health care. In 2000, with the inclusion of the Armed Forces and with supplementary resources began the Plan Bolívar 2000, which is directed to pay the “sanitary debt” and to lighten the waiting lists of people suffering the most common and easy visible health problems with health actions and surgical interventions.
For all these reasons structural changes were made to the health care system and the Misión Barrio Adentro arises, which is supported by the Integral Agreement of Cooperation between the Republic of Cuba and the Bolivarian Republic of Venezuela. It began to operate formally on May 22nd, 2003 with the signing of the Agreement Act between the Libertador Municipality and the Medical College of the Caracas Metropolitan District. It is directed to provide health care to 171 barrios with the participation of 200 Cuban doctors and 30 Venezuelan; the initial investment was one billion Bolívares.
With Misión Barrio Adentro as the axis of the health state policy to transform the entire National Public Health System, the People Health Centers were created as the primary level of health attention with a coverage of one doctor for 250 families (1,250 persons approximately) in a health team integrated by the former health worker, one nurse and one community health promoter. For every People Health Center, a Community Meeting Center (which is called Life and Health Home) was established. In the Life and Health Home works a Health Committee that aids the health team and tries to operate a Popular Drugstore to provide medicines at low cost. The construction of 5,000 People Health Centers was decided in 2004; fifty eight have been built and 242 are under construction in the Libertador municipality (Caracas Metropolitan District) and Sucre (Miranda State). It is expected to hand 1,800 Centers over in other states.
In the second level of health attention, People Clinics will be established; these facilities will have a high resolution capacity and will provide care to patients sent by the People Health Centers. Personnel working in these Clinics will comprise specialist doctors, dentists and other support services. The Clinics will have High Technology Diagnostic Equipment. The Clinics will offer emergency and ambulatory care 24 hours and 12 hours a day respectively.
In the third level of health attention, it is planned the creation of the People Hospitals which will be the most complex health care facilities to provide care to patients sent by the first and second levels. Medical care will be provided by specialist and sub-specialist doctors supported by High Technology Diagnostic and Treatment Equipment.
Health Promotion and vulnerable groups
Judiciary bases for Health Promotion established in the CBRV have allowed the proposal of legal tools as the Law Project on Community Participation and the Organic Law of Child and Adolescent Protection. In this context the HSDM has proposed health promotion and social development as the principal axes around all actions must be developed.
Priority areas for the promotion approach:
Mental Health: It is necessary to strengthen the register systems of information related to mental health. Available data come from registers of the attention demanded in specialized attention centers and do not include the attention demanded in the first level facilities.
This reflects an approach centered in the disease, whose main axes are the psychiatric hospital and long-stay establishments (psychiatric colonies). Compromises assumed by the country in the 1990 Caracas Statement involve the integration of the mental health services, ambulatory and hospital care to the network services with an effective community participation
Accidents and violence: During the 1998-2000 period intrafamily violence episodes amounted 4,000 accusation per year. The 800MUJER (800WOMAN, in English) phone number informed that 57.7% of all calls were related to violence against women and family. Although this problem has been defined as a national priority (INAMUJER assigns it more than 70% of its budget) there are still many restraints referred mainly to the lack of a national system of reference and registration of the information as well as protocols for the registry and adequate care of this problem. The Interministerial Commission for Attention, Prevention and Road Education was created in 2003. In 2004 the HSDM National Program on Accidents and other violence deeds.
Drug dependency: A study carried out in 1998, revealed that most drug addicts were single men, aged 20-29, with an incomplete secondary schooling, unemployed, who started consuming marijuana, alcohol or cocaine before 20 years of age. The same study revealed that consumption began at a very early age (10-19 years), especially with alcohol and tobacco. There is a rising trend in the use of psycho-drugs, alcohol, and tobacco among women. In 2000, 43.9% of traumas and 28.1% of injuries occurred in people that drank alcohol in the last six hours before the accident. In comparison, 10.4% of traumas, and 3.5% of injuries occurred among people who did not drink. Efforts made to tackle the problem have been insufficient, being the lack of coordination among institutions and the inadequate design of inter-sectorial preventive programs directed to the high-risk groups, the most important factors involved in the failure.
Smoking: Prevalence among adults fell from 39.8% in 1984 to 30% in 1997. However, in people under 15 years of age, it rose from 2.7% to 7% in the same period, especially among women. Cigarette consumption per capita has fallen from 1,893 units in 1984 to 897 in 1997. It is necessary to strengthen the legislation oriented to the group under 15, and especially to the absolute banning of tobacco advertising. Since 2003, the HSDM began a regulation and sanitary control policy on tobacco products and two ministerial resolutions were passed; the first deals with a new system of health warning using inscriptions and pictorials occupying one of the front sides of the cigarette package, and forbidding the use of terms like “soft”, “smooth”, etc., in all cigarette packages and other tobacco products. The second resolution turns mandatory the tobacco sanitary regulation and control, and it allows authorities the analysis and monitoring of components and toxic emissions of tobacco products with the purpose to establish maximum tolerable levels.
Food and Nutrition: In the last years, there has been a reduction in the fulfillment of the energy needs, especially among the lower income strata. The country is classified in the critical autonomy category, as 47.1% of total calories came from imported food. In 2000, the most affected groups by malnutrition were children under 2 years of age (11.7%), preschool children aged 2-6 years (22.4%) and school children aged 7-14 years (24.4%). Nutritional deficit observed in preschool children attending public schools is 24.7%. Mortality due to malnutrition affected more children under 1 year; it rose from 39.7 per 100,000 live newborns (1989) to 60.3 in 1999. Prevalence of overweight in children under 15 years of age increased from 8.5% in 1990 to 11.3% in 2000. In 2000 Venezuela was certified as Virtually Free from DDI.
Food availability in 1999 was fully satisfied (higher than 110%) for proteins, iron, vitamin A and C, thiamine and niacin. However, the availability of calories, riboflavin and calcium was classified as critically insufficient (less than 90%). The challenge is to achieve a fair access to macro and micronutrients by the vulnerable groups. The National Committee of the Codex Alimentarium began to operate in January, 2003 opening a discussion forum that integrates the public and private sectors and binds them to food control procedures and founding the bases that will allow the reversion of this situation and the modernization of food control at a national level.
Oral Health: In 1997-1998, the tooth decay index (in deciduous or permanent teeth) in six-year old children reflected an average of three affected teeth; in permanent teeth the DFM average up to eight-year old children was lower than one tooth (perhaps due to the transition stage of the mixed dentition). The established PAHO goal of a DFM index of three teeth in children aged 12 was improved (DMF of 2.12 teeth). However, by the age of 15 years the DMF index is above three which could be aggravated by adult age.
Health and Environment: 17% of the Venezuelan territory is classified as environmental protected areas (ABRAE, in Spanish). There is an Environment Criminal Law and a body of rules and norms that are constantly updated. The sanitary-environmental surveillance lacks of laboratory capacity, trained workers and research.
Water resources: Drinking water coverage rose from 77% in 1996 to 84% in 2000. Non-covered areas are mainly rural, indigenous and non-consolidated urban areas. The country has 125 potabilization plants, most of them located within the water works that supply urban zones guaranteeing the quality of water. In relation with its design capacity this infrastructure is insufficient. There are deficiencies in the control and surveillance of the services in rural zones and as a consequence, the quality of water is dubious.
Wastewater: In 2000, 73% of the national population have wastewater systems; the deficit is concentrated in rural, indigenous and non-consolidated urban areas, where only 10% of wastewater is treated. Although, the annual public investment in the sector has not amounted 0.2% of the GDP in the last five years, in 2001 the National Sanitation Plan was consolidated with additional resources (88.9 million USD), a budget increase of 26.7% for the sector. Non-counted water (NCW) is a fundamental issue of great incidence in the financing deficit of the sector. NCW represented in 1996 a national average of 62%.
Solid waste management: 72% of all municipalities lack infrastructure for the sanitary disposal of solid waste and the country does not have safe containment landfills for solid waste, including hospital infectious solid waste. Currently, the legal frame which allows to respond to this problem is being developed. The Solid Waste Law was proposed in 2003 and guidelines for Regional Plans for the Management of Solid Waste have been implemented. Landfills for the final disposal of solid waste have been built and restored. At a national level the sanitary environmental handling of solid waste is still a significant problem.
Atmospheric monitoring: At a national level, it is done through an instrumental network which has detected an increase in the pollutant levels, especially in particulate matter in the industrial areas of Zulia and Bolívar States. Public institutions have applied control measures, like the removal of leaded gasoline in 2005, and the promotion of the use of natural gas and unleaded gasoline in motor vehicles. During 2003, studies and researches on environmental problems, especially in developing industrialized zones, have been carried out; environmental liabilities on this issue are elevated and they are closely linked to the technology in use.
Occupational health and industrial hygiene: In the last decade, occupational risk tends to increase, even with the existing under-registration, as a direct consequence of informal labor, the use of inadequate facilities, even the use of the household as a production center. The main occupational diseases are the industrial deafness and other pathologies associated to noise and vibrations, poisoning due to chemical compounds and musculo-skeletal diseases. The national government has established workers health as one of its policies, but social security is still developing and there are significant problems due to the high number of sub and unemployed people.
Natural Disasters: The HSDM does not have a the central, regional or local organization to cope with a disaster situation. In most health facilities there are no plans to face emergencies. Currently, measures to improve the institutional capacity through technical cooperation with the Andean countries are being taken. In 2003, the Civil Protection Law was passed and efforts are made to promulgate its regulations. In the same year, the Venehmet project on information of meteorological events became concreted. Also in 2004, the appointment of the Ministerial Committee for the development of the Emergencies and Disasters Plan of Health Sector became concreted as well as the Operational Plan of the different directions that are involved. The Unified Medical Assistance Plan (CUMA, in Spanish) which is responsibility of the Military Public Health, Defense Ministry has been updated. Studies and researches over Risk Assessment in different zones of the country are available; these studies were done with the support of JICA-JAPAN in the Caracas Metropolitan Area in 2004.
Food Safety: To guarantee the food safety, the HSDM is responsible in all the country for the registration of food products and of their innocuity from industry to consumption. There are not control procedures for residues of veterinary drugs that could contaminate food, nor measures directed to the control of genetically modified crops. However, the Environment and Natural Resources Ministry has worked on the development of the Biological Biodiversity Law, approved by the National Assembly, and its rules are under revision. The HSDM began in 2003, the implementation of the HACCP system in the food industry and in the fast food restaurant chains of the country.
Expenditure and Sector Financing: Public health expenditure of the national budget rose from 8.6% in 1995 to 11.6% in 2000. Public and private health expenditure as a percentage of the GDP has oscillated; in 1995 it was 2.6%, then fell to 2.0% in 1996, thereafter it rose to 2.7% in 1997 and maintained an ascending trend until 2000 when it amounted 3.0%. The same situation was observed for the public expenditure per capita, l which was of 34.1 USD in 1995, then fell to 23.8 USD in 1996, and afterwards it rose to 62.2USD in 2000. During the 1995-1999 period, the health expenditure of the central government, as a percentage of the GDP, fell from 1.5% to 1.3%. Private expenditure has risen more than public expenditure, and in 1999 it represented more than 50% of total expenditure (1.6% of GDP). 6.6% of the National Fiscal Budget was assigned to the HSDM (2,108,150,100 USD). 74% of this budget was transferred to organisms of the HSDM and to the states. The assignment per capita ranged from 76 USD (Apure State) to 24 USD (Miranda State); this figures make clear the efforts to privilege equity in the process.
During the 1995-2002 period, the public health system is financed in 79% by the Public Budget, 20.3% by payments to the Social Security, and 0.84% by taxes paid to other Contributive Public Systems. Public health expenditure corresponding to 2001 was 3,010,265.7 Bolívares (3.3% of the GDP). This means an increase of the public expenditure, though insufficient, in comparison with the behavior of previous years. Health expenditure financed by Public Funds passed from 7.65% of the National Budget in 1995 to 12.11% in 2002. Although, private health expenditure is not well quantified, it is considered approximately in 7% of the GNP, which means that the national health expenditure is mostly private.
According to the Constitution of the Bolivarian Republic of Venezuela, the HSDM has the mandate to regulate and control the Health System, including public and private facilities that provide health care services as well as the health financing to assure solidarity and equity in the system. The proposals of an Organic Law that have been presented to the National Assembly, include the strengthening of the rule of the Public Health System and the State to fulfill the Essential Functions of Public Health and the Extension of the Health Social Protection that assure an efficient, fair, supportive, high-quality health care and with a prominent community participation.
The Health Information National System is in charge of the collection, analysis and use of the epidemiological information as well as the related to health programs and services, costs and expenses, medical practice. These functions are carried out in a dispersed way by different branches of the HSDM and the states.
Human Resources: In 2000, there were 20.7 doctors per 10,000 inhabitants. A study done in 2001 by the Medicine School of the Central University of Venezuela found that there were 31,513 medical positions in the Public Health System over a total of 46,094 active doctors. Positions are distributed in the HSDM according to the following way: of 14,181 positions, 75% (10,640) are for specialists; 4.9% (692) are for permanent APS, and 20.1.% (2,849) are for temporary APS. The HSDM has 3,541 positions for the APS; this figure represents 25% of all positions. 80% of those positions are for transitory APS.
Nearly 24,600 nurses (8,200 qualified nurses and 16,400 auxiliaries) besides 32,800 community promoters are required to integrate the basic teams. Currently, there is a significant deficit of nurses in all the country. In 2001, there were 1,819 qualifies nurses (0.7 per 10,000 inhabitants). In the same year, there were 23,024 auxiliary nurses (9.3 per 10,000) as well as 3,157 University Technical Superior Auxiliary nurses (TSUE, in Spanish) (1.3 per 10,000).
The HSDM regulates and supervises all issues related to medicines management, from their manufacturing to their usage in patients. Medicine expenditure of the HSDM and the IVSS amounts 15.2% of total health expenditure. National demand is met by local producers and medicine importers. National production has diminished from 95% in 1995 to 45% in 2000. In the last years total medicine expenditure has risen from 1.2 billion USD to 1.6 billion USD in 2000. However, the access, indirectly estimated by a consumption indicator like the number of units per capita, has fallen from 18 units per capita in 1977 to 13 in 2000. In 2000, 34% (544 million USD) of total medicine expenditure corresponded to the public sector. The HSDM is designing a National Medicine Policy which is mainly based on securing the access to basic medicines.
